PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION {PNF}

             PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION

1.      HISTORY

·         PNF originated with Dr. Herman Kabat, physician and neurophysiologist, in the 1940s. He applied neurophysiologic principles, based on the work of Sherrington, to interventions for paralysis secondary to poliomyelitis and multiple sclerosis. 

·         In 1948, Kabat and Henry Kaiser founded the Kabat-Keiser Institute in Vallejo, California. Here, Kabat worked with PT Margaret Knott to develop the PNF method of intervention. By 1951 the diagonal patterns and core techniques were established. PNF is now used to treat numerous neurologic, musculoskeletal, and general medical conditions. 

·         In 1952 Dorothy Voss, a PT, joined the staff at the Kaiser-Kabat Institute. She and Knott undertook the teaching and supervision of staff therapists.

·         In 1954 Knott and Voss presented the first 2-week course in Vallejo. Two years later, the first edition of Proprioceptive Neuromuscular Facilitation by Margaret Knott and Dorothy Voss was published by Harper & Row. During this same period several reports in the American Journal of Occupational Therapy described PNF and its application to occupational therapy intervention.It was not until 1974 that the first PNF course for OTs, taught by Dorothy Voss, was offered. Since then, Beverly

·         Myers, an OT, and others have offered courses for OTs throughout the United States. In 1984, PNF was first taught concurrently to both PTs and OTs at the Rehabilitation Institute in Chicago.

2.      THEORY

·         PNF is based on normal  movement and            motor development.   

·         In normal motor   activity            the brain registers total            movement and            not individual muscle            action.

·         The PNF  approaches use            mass movement patterns that resemble           normal movement     during  functional activities.   

·         Facilitation techniques are superimposed on these movement patterns  and      postures through manual contacts, verbal commands, and visual cues.

3.      PRINCIPLES OF TREATMENT

·     Normal motor development proceeds in a cervicocaudal and proximodistal direction

·         Early motor behavior is dominated by reflex activity

·         Motor behavior is expressed in an orderly sequence of total patterns of movements and posture

·         The growth of motor behavior has a rhythmic and cyclical trend, as evidenced by shifts between flexor and extensor dominance.   

·      Normal motor development has an orderly sequence but lacks a step-by-step quality

·         Establishing a balance between antagonists is a main objective of PNF

·         Improvement in motor ability depends on motor learning.         

·      Goal-directed activities  coupled with techniques  of facilitation are used to has learning of total patterns of walking and self-care activities

4.      MOTOR LEARNING

·         Motor learning requires a multisensory approach;            auditory, visual,and tactile systems are all used to achieve the desired response.      

·     The correct combination of sensory input for each patient should be identified and altered as the person  progresses.

4.1.Auditory System

·         Verbal commands should be brief and clear. It is important to time the command so that it does not come too early or too late in relation to the motor act.

·         Tone of voice may influence the quality of the client’s response. 

·         Tones of moderate intensity evoke gamma motor neuron activity and that louder tones can alter alpha motor neuron activity.

·         Strong, sharp commands simulate a stress situation and are used when maximal stimulation of motor response is desired.

·         A soft tone of voice is used to offer reassurance and to encourage a smooth movement, as in the presence of pain

4.2.Visual System

·         Visual stimuli assist in initiation and coordination of movement. Visual input should be monitored to ensure that the client is tracking in the direction of movement

·         To achieve the goal of increased head, neck, and trunk rotation. Because occupational therapy is activity oriented, an abundance of visual stimuli is offered to the client.

4.3.Tactile System

·         Developmentally the tactile system matures before the auditory and visual systems.

·         The tactile system is more efficient because it has temporal and spatial discrimination abilities, as opposed to the visual system

·         The PNF approach uses the concepts of part-task practice and whole-task practice. In other words, to learn the whole task, emphasis is placed on the parts of the task that the client is unable to perform independently.

·         The use of tactile input is            essential to guide and reinforce          the desired the pattern of movement

5.      ASSESSMENT :

·         Assessment of the client requires astute observational skills and knowledge of normal movement.

·         An initial assessment is performed to determine the client’s abilities, deficiencies, and potential.

·         After the intervention plan is established, ongoing assessment of the client is necessary to ascertain the effectiveness of intervention and to make modifications as the client changes.

·         The PNF assessment follows a sequence from proximal to distal.

1.      Vital functions are considered, such as breathing, swallowing, voice production, facial and oral musculature, and visual-ocular control

2.      The head and neck region is observed after vital functions. Head and neck positions are observed in varying postures and total patterns during functional activities. It is important to note

Ø  Dominance of tone (flexor or extensor),

Ø  Alignment (midline or shift to one side)

Ø  Stability and mobility (more or less needed).49 After observation of the head and neck region,

3.      The assessment proceeds to the following parts of the body: upper part of the trunk, upper extremities (UEs), lower part of the trunk, and lower extremities (LEs). Each segment is assessed individually in specific movement patterns

6.      TREATMENT:

·         The treatment techniques used           in the PNF approach are diagonal patterns, total patterns and facilitation techniques

6.1.DIAGONAL PATTERNS

·         The diagonal patterns used in the PNF approach are the mass movement patterns observed in most functional activities.

·         Occupational therapy assessment and intervention is recognition of the diagonal patterns in ADLs.

·         Two diagonal motions are present for each major part of the body: head and neck, upper and lower parts of the trunk, and extremities. Each diagonal pattern has a flexion and extension component, together with rotation and movement away from or toward the midline.

·          The UE and LE diagonals are described according to the three movement components at the shoulder and hip:

Ø  Flexion and extension 

Ø  Abduction and adduction

Ø  External and internal rotation.

·         Voss introduced shorter descriptions for the extremity patterns in 1967 and referred to them as diagonal 1 (D1) flexion/extension and diagonal 2 (D2) flexion/extension.

        Unilateral Patterns

·         UE D1 flexion (shoulder flexion-adduction–external rotation): Scapula elevation, abduction, and rotation; shoulder flexion, adduction, and external rotation; elbow in flexion or extension; forearm supination; wrist flexion to the radial side; finger flexion and adduction; and thumb adduction. and D1 flexion is called reverse of chop.

         Examples in functional activity:

Ø  Hand-to-mouth motion in feeding

Ø  Tennis forehand

Ø  Combing the hair on the left side of the head with the right hand

Ø  Rolling from supine to prone.

·         UE D1 extension (shoulder extension-abduction– internal rotation): Scapula depression, adduction, and rotation; shoulder extension, abduction, and internal rotation; elbow in flexion or extension; forearm pronation; wrist extension to the ulnar side; finger extension and abduction; and thumb in palmar abduction . D1 extension, when performed in a bilateral asymmetrical pattern, is called chopping.

              Examples in functional activity:

Ø  Pushing a car door open from the inside

Ø  Tennis backhand stroke

Ø  Rolling from prone to supine

·          UE D2 flexion (shoulder flexion-abduction–external rotation): Scapula elevation, adduction, and rotation; shoulder flexion, abduction, and external rotation; elbow in flexion or extension; forearm supination; wrist extension  to the radial side; finger extension and abduction; and thumb extension. D2 flexion, when performed in a bilateral asymmetrical pattern is called lifting.

          Examples in functional activity:

Ø  Combing the hair on the right side of the head with the right hand

Ø  Lifting a racquet in a tennis serve, and back stroke in swimming.

·         UE D2 extension (shoulder extension-adduction– internal rotation): Scapula depression, abduction, and rotation; shoulder extension, adduction, and internal rotation; elbow in flexion or extension; forearm pronation; wrist flexion to the ulnar side; finger flexion and adduction; and thumb opposition. D2 extension is called reverse of lift

          Examples in functional activity:

Ø  Pitching a baseball

Ø   Hitting a ball during a tennis serve and buttoning pants on the left side with the right hand

·         LE D1 flexion (hip flexion-adduction–external rotation): Hip flexion, adduction, and external rotation; knee in flexion or extension; and ankle and foot dorsiflexion with inversion and toe extension.

                  Examples in functional activity:

Ø  Kicking a soccer ball

Ø  Rolling from supine to prone, and putting on a shoe with the legs crossed

·         LE D1 extension (hip extension-abduction–internal rotation): Hip extension, abduction, and internal rotation; knee in flexion or extension; and ankle and foot plantar flexion with eversion and toe flexion.

                  Examples in functional activity:

Ø  Putting a leg into pants and rolling from prone to supine

·         LE D2 flexion (hip flexion-abduction–internal rotation): Hip flexion, abduction, and internal rotation; knee in flexion or extension; and ankle and foot dorsiflexion with eversion and toe extension.

                  Examples in functional activity:

Ø  Karate kick and drawing the heels up during the breaststroke in swimming.

·         LE D2 extension (hip extension-adduction–external rotation): Hip extension, adduction, and external rotation; knee in flexion or extension; and ankle and foot plantar flexion with inversion and toe flexion.

                 Examples of functional activity:

Ø  Push-off in gait, the kick during the breaststroke in swimming, and long sitting with the legs crossed

      Bilateral Patterns Movements

·         Symmetric patterns: Paired extremities perform similar movements at the same time  

                                Examples:

Ø  Bilateral symmetric D1 extension, such as pushing off a chair to stand 

Ø  Bilateral symmetric D2 extension, such as starting to take off a pullover sweater

Ø  Bilateral symmetric D2 flexion, such as reaching to lift a large item off a high shelf

Ø  Bilateral symmetric UE patterns facilitate trunk flexion and extension.

·         Asymmetric patterns: Paired extremities perform movements toward one side of the body at the same time, which facilitates trunk rotation. The asymmetric patterns can be performed with the arms in contact, such as in the chopping and lifting patterns in which greater trunk rotation is seen

     Examples:

Ø  Asymmetric patterns are bilateral asymmetric flexion to the left with the left arm in D2 flexion and the right arm in D1 flexion, such as when putting on a left earring

Ø   Bilateral asymmetric extension to the left with the right arm in D2 extension and the left arm in D1 extension, such as when zipping a left-sided zipper.

·         Reciprocal patterns: Paired extremities perform movements in opposite directions          at the same time. Reciprocal patterns have a stabilizing effect on the head, neck,       and trunk.     

                 Examples          :          

Ø  Pitching            in baseball or walking on a balance beam with           one extremity in a diagonal flexion pattern and the other in a diagonal extension pattern          

6.2.COMBINED MOVEMENTS OF THE UPPER AND LOWER EXTREMITIES:

·         Interaction of the UEs and LEs results in 

Ø  Ipsilateral patterns, with extremities on the same side moving in the same direction at the same time

Ø  Contralateral patterns, with extremities on opposite sides moving in the same direction at the same time

Ø  Diagonal reciprocal patterns, with contralateral extremities moving in the same direction at the same time while the opposite contralateral extremities move in the opposite direction

7.      SEVERAL FACTS SUPPORT THE USE OF TOTAL PATTERNS IN THE PNF INTERVENTION APPROACH:

                                                                     I.            Total patterns of movement and posture are experienced as part of the normal developmental process in all human beings. Therefore, recapitulation of these postures is meaningful to the client and acquired with less difficulty.

                                                                  II.            Movement in and out of total patterns and the ability to sustain postures enhance components of normal development, such as reflex integration and support, balance between antagonists, and development of motor control in a cephalocaudal, proximodistal direction.

                                                               III.            The use of total patterns improves the ability to assume and maintain postures, which is important in all areas of occupation

8.      PROCEDURES:

8.1.Manual contact

·         Manual contact refers to placement of the therapist’s hands on the client.

·         Contact is most effective when applied directly to the skin. Pressure from the therapist’s touch is used as a facilitating mechanism and serves as a sensory cue to help the client understand the direction of the anticipated movement.

·         The amount of pressure applied depends on the specific technique being used and on the desired response.

·         The location of manual contact is chosen according to the groups of muscles, tendons, and joints responsible for the desired movement patterns.

·         Manual contact should be on the posterior surface of the scapula to reinforce the muscles that elevate, adduct, and rotate the scapula.

8.2. Stretch

·         Stretch is used to initiate voluntary movement and enhance speed of response and strength in weak muscles.

·         When a muscle is stretched, the Ia and II fibers in the muscle spindle send excitatory messages to the alpha motor neurons that innervate the stretched muscle. Inhibitory messages are sent to the antagonistic muscle simultaneously.

·         When stretch is used in the PNF approach, the part to be facilitated is placed in the extreme lengthened range of the desired pattern (or where tension is felt on all muscle components of a given pattern).

·         The client should attempt the movement at the exact time that the stretch reflex is elicited. The use of verbal commands also should coincide with the application of stretch to reinforce the movement. Discrimination should be exercised with use of stretch to prevent an increase in pain or muscle imbalance.

8.3.Traction

·         Traction facilitates the joint receptors by creating a separation of the joint surfaces.

·          It is thought that traction promotes movement and is used for pulling motion.

8.4.Approximation

·         Approximation facilitates joint receptors by creating compression of the joint surfaces. It promotes stability and postural control and is used for pushing motion.

·         To enhance postural control

·         To enhance proximal stability

8.5.Maximal resistance

·         Maximal resistance the procedure is defined as the greatest amount of resistance that can be applied to an active contraction while allowing full ROM to take place or that can be applied to an isometric contraction without defeating or breaking the client’s hold.

·         The objective is to obtain maximal effort on the part of the client because strength is increased by movement against resistance that requires maximal effort.

9.      TECHNIQUES:

These techniques are divided into three categories: those directed to the agonists, those that are a reversal of the antagonists, and those that promote relaxation.

9.1.DIRECTED TO THE AGONIST:

                      Repeated contractions

·         Repeated contractions based the on assumption that repetition of an activity is necessary for motor learning and helps develop strength, ROM, and endurance.

·         The client’s voluntary movement is facilitated with stretch and resistance by performing isometric and isotonic contractions.

                     Rhythmic initiation

·         Rhythmic initiation is used to improve the ability to initiate movement

·         This technique involves voluntary relaxation, passive movement, and repeated isotonic contractions of the agonistic pattern.

·         The verbal command is, “Relax and let me move you.” As relaxation is felt, the command is, “Now you do it with me.” After several repetitions of active movement, resistance may be provided to reinforce the movement.

·         Rhythmic initiation allows the client to feel the pattern before beginning active movement. Thus, the proprioceptive and kinesthetic senses are enhanced.

9.2. TECHNIQUES INVOLVE REVERSAL OF THE  ANTAGONIST

                    

                     Slow reversal

·         Slow reversal is an isotonic contraction (against resistance) of the antagonist followed by an isotonic contraction (against resistance) of the agonist.

·         Slow reversal–hold is the same sequence, but with an isometric contraction at the end of the range.

·         An increase or buildup of power in the agonist should be felt with each successive isotonic contraction.

                   Stabilizing reversals

·         Stabilizing reversals are characterized by alternating isotonic contractions opposed by enough resistance to prevent motion.

·         In practice, the therapist provides resistance to the client in one direction while asking the client to oppose the force, with no motion allowed. Once the client is fully resisting the force, the therapist gradually moves the resistance in another direction. Each time that the client is able to respond to the new resistance, the therapist moves the hand to resist a new direction, with directions reversed as often as needed to achieve stability.

·         This technique is used to increase stability, balance, and muscle strength.

                 Rhythmic stabilization

·         Rhythmic stabilization is used to increase stability by eliciting simultaneous isometric contractions of antagonistic muscle groups.

·         This technique requires repeated isometric contractions, which leads to increased circulation or the tendency for the client to hold his or her breath, or both.

·         In rhythmic stabilization, manual contact is applied to both agonist and antagonist muscles, with resistance given simultaneously. The client is asked to hold the contraction against graded resistance. Without allowing the client to relax, manual contact is switched to the opposite surfaces.

·         Rhythmic stabilization techniques were found to be effective in improving postural control and reducing pain in individuals who had chronic low back pain.

9.3.RELAXATION TECHNIQUES

Relaxation techniques are an effective means of increasing ROM, particularly in clients with pain or spasticity, which may be increased by passive stretch.

                     Contract-relax

·         Contract-relax involves passive motion to the point of limitation in movement patterns.

·         This is followed by an isotonic contraction of the antagonist pattern against maximal resistance, with only the rotational component of the diagonal movement allowed. This action is followed by relaxation and then by further passive movement into the agonistic pattern

·         Contract-relax is used when no active range in the agonistic pattern is present

·         Isotonic contraction of antagonist pattern (“Turn and pull” or “Turn and push”) and resist

·         Relaxation

·         Passively move through new available range; repeat

·         Passive or active-assisted movement in the agonist pattern until limit is felt

·         Indication: When agonist is weak

                      Hold-relax

·         Hold-relax is performed in the same sequence as contract relax but involves an isometric contraction (no movement allowed) of the antagonist, followed by relaxation and then active movement into the agonistic pattern.

·         It has been recommended that the static contraction be held for 3 seconds to achieve the greatest improvement in ROM

·         Indication: Muscle spasm with pain

                      Slow reversal–hold-relax

·         Slow reversal–hold-relax begins with an isotonic contraction, followed by an isometric contraction, relaxation of the antagonistic pattern, and then active movement of the agonistic pattern. When the client has the ability to move the agonist actively, the technique is preferred

·         Indication: When the patient has the ability to move the agonist

·         Isometric contraction of the antagonist

·         Isotonic contraction of the antagonist

·         Active movement of the agonist

·         Relaxation

                      Rhythmic rotation

·         Rhythmic rotation is effective in decreasing spasticity and increasing ROM. The therapist passively moves the body part in the desired pattern. When tightness or restriction of movement is felt, the therapist rotates the body part slowly and rhythmically in both directions.

·         Perform PROM until resistance is met

·         Indication: Hypertonicity

·         Slowly and gently repeat and reverse rotation of all limb segment Continue PROM and repeat